REVISION JOINT REPLACEMENT SURGERY

Of course, total joint surgery is one of the most successful surgeries of the century. But it may also fail sometimes.

The goal of the total joint replacement surgery is to relieve the pain of the deformed arthritic joint and make your life happy and pain-free. But if something goes wrong some time then the patient may start feeling pain again. Pain while walking, while getting up and sometimes continuous pain even at rest indicates that something is wrong.

Resurgery or revision joint replacement surgery is required when the primary joint replacement surgery fails. This revision surgery is far more different than the primary joint replacement surgery.

Revision surgery is far more complex and needs extensive workup and planning for the surgery.

First, we will see the causes or reasons for the revision surgery.

1) Loosening:

Every artificial implant has a certain life. You may have “outlived the life of the implant. At the primary surgery, the artificial implant is fixed to the surface of your bone with the help of cement. Sometimes we use the uncemented technique where the provision is made to promote the bone growth and so fix the implant. Damage to the implant can. occur due to some impact activity, obesity. or trauma.

Poly (Ultra high molecular weight polyethene) in between the articulating metal implant may wear down leading to loosening. Small particles of the polyethene may get separated due to wear, abrasion. These particles may excite patient’s own. immune system and form immune complexes. These further attack the bone leading to osteolysis”

Such wear is the characteristic of the articulating material we use. Less wear is with Oxnium, Ceramic material. Scientist across the world are working hard to find out. a material which will lead to less wear and so help for the long survival of the implant and surgery. Vitamin e mixed poly, Oxidised poly is such examples.

What will happen to the patient if the implant.

gets loosened? Prominent symptoms will be a pain, It’s mechanical pain most of the time. Means you will feel the pain only on activity, walking, or standing. Deformity may increase. Climbing up the stairs or getting up from the chair may be difficult.

2) Infection:

Infection is something which is very

undesirable. It’s difficult to tackle as well. As we have seen infection is related to the operation room quality, operating conditions. bacterial load in the patients blood or urine before surgery and of course patient simmunity.

Every single precaution is taken at our institute to achieve zero infection rate. We have double laminar airflow system with high-quality filters. We never operate without a space suit and hood. Infection can be acute (within 3 weeks), or chronic.

Infection can be at the time of surgery or can be late onset (Blood born). Late onset is from the other sources of infection from the distant site.

Clinical presentation of infection includes: systemic signs as fever, continuous throbbing pain, pain on every activity as well as rest pain. Local signs include redness,

warmth, and discharging sinus from where the blood or pus is coming out. Diagnosis of infection is done with local systemic signs and confirmed with tissue or intra articular fluid culture diagnosis.

3) Mal alignments:

Mal alignment of the component is one of the prominent reasons for the painful arthroplasty or anterior knee pain after the surgery. It often results into the lateral mal-tracking of patella leading to anterior knee pain.

The mismatch between the flexion and extension gap lead to either postoperative flexion deformity or loose flexion. Mid flexion instability also leads to the unsatisfactory results after the arthroplasty. Pain while getting up from the chair or pain while climbing up or climbing down the stairs

is the prominent symptom of it. Persistent deformity or under correction of the deformity also will lead to early failure of the primary surgery.

4) Fracture of the bone or implant

Bone adjacent to the implant may get fracture because of fall or trauma leading to what is known as periprosthetic fractures. If the fracture involves the very proximity of the implant then we may need to completely revise the surgery with new implant

I have seen and explanted broken implant as

well.

Technique and implant of revision arthroplasty

In case of infection, we go for two-stage. revision-

1. The first stage is confirmation of diagnosis Explantation (taking out) of the primary implant keeping an antibiotic spacer inside. Intravenous antibiotics are given according to the culture sensitivity report for at least 6 weeks. Patient condition is monitored with serial blood tests. Once the infection subsided with the blood parameters in normal range, then we go for second stage surgery In case of aseptic loosening leading to revision surgery or mal alignment leading to revision surgery, we go for single stage. surgery.

The technique involves taking down the previous implant with minimum damage to the host bone. Cleaning of the surfaces and then fuxing new implant with the help of cement and rods.

Revision arthroplasty implant is altogether different as it has to take into account all possible bone loss and damages to the host bone. It needs a huge inventory which includes all sorts and sizes of stems, wedges, augments, fillers.

The goal of revision surgery is same as primary arthroplasty surgery. Painless mobile joint free from any deformity is the goal of the surgery. But the complication rate is obviously high than the primary arthroplasty. Also, the survivorship of revision arthroplasty is less compared with the primary arthroplasty surgery.

Revision arthroplasty is one of the most challenging surgeries and needs extensive training and experience